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Pressure Injury

NCLEX Review Guide: Pressure Injuries

Pressure Injury Overview

Definition and Etiology

  • Pressure injuries (formerly called pressure ulcers or decubitus ulcers) are localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, resulting from intense and/or prolonged pressure or pressure in combination with shear forces.
  • Primary causes include pressure, shear, friction, moisture, and immobility, with risk factors including advanced age, poor nutrition, decreased sensation, and impaired circulation.

Key Points

  • Always assess patients at risk for pressure injuries using a validated tool such as the Braden Scale.
  • The NPUAP staging system is the standard for classifying pressure injuries and guides treatment approaches.

Pressure Injury Staging

  • Stage 1: Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.
  • Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or ruptured serum-filled blister.
  • Stage 3: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
  • Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.
  • Unstageable: Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
  • Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Pressure Injury Staging Comparison

Stage Tissue Involvement Appearance Key Characteristics
Stage 1 Epidermis only Non-blanchable redness Intact skin, may feel warm/firm
Stage 2 Partial-thickness (epidermis/dermis) Shallow open ulcer or blister Pink-red wound bed, no slough
Stage 3 Full-thickness Crater-like wound Subcutaneous fat visible, no bone/muscle exposed
Stage 4 Full-thickness with extensive damage Deep crater with exposed structures Bone, tendon, or muscle visible
Unstageable Unknown depth Covered with slough/eschar Cannot determine depth until debridement
Deep Tissue Injury Damage to deep tissues Purple/maroon intact skin or blister May rapidly deteriorate despite treatment

Key Points

  • Never reverse-stage pressure injuries; as they heal, they do not progress backward through the stages but are described as "healing Stage 4" or "healing Stage 3."
  • Deep Tissue Injuries can rapidly evolve into higher stage injuries even with optimal treatment, requiring vigilant monitoring.

Prevention and Risk Assessment

Risk Assessment Tools

  • The Braden Scale is the most commonly used validated tool for pressure injury risk assessment, evaluating six parameters: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
  • Other assessment tools include the Norton Scale and Waterlow Scale, with scores indicating risk levels that guide preventive interventions.

Braden Scale Memory Aid: "SAM NFR"

Remember the six Braden Scale components with:

  • Sensory Perception
  • Activity
  • Mobility
  • Nutrition
  • Friction & Shear
  • Risk from Moisture

Lower scores indicate higher risk (total score range: 6-23)

Key Points

  • Conduct risk assessments on admission, at regular intervals, and with any significant change in patient condition.
  • A Braden Scale score of 18 or less indicates at-risk status; scores of 12 or less indicate high risk.

Preventive Interventions

  • Repositioning: Change patient position every 2 hours when in bed and every 1 hour when seated, using the 30-degree tilted side-lying position to reduce pressure on bony prominences.
  • Support surfaces: Utilize pressure-redistributing mattresses, overlays, and cushions appropriate to the patient's risk level and needs.
  • Skin care: Keep skin clean and dry, using pH-balanced cleansers and moisturizers to maintain skin integrity and prevent excessive dryness or moisture.
  • Nutrition: Ensure adequate protein, calorie, and fluid intake, with possible supplementation for at-risk patients.
  • Moisture management: Implement incontinence management programs and use moisture barriers to protect skin from excessive exposure to moisture.

Critical Prevention Alert

Never massage reddened areas or bony prominences as this can cause deep tissue damage. Avoid positioning directly on the trochanter when using side-lying positions, and ensure heels are completely off the surface (floating) for high-risk patients.

    Proper Repositioning Procedure

  1. Explain procedure to patient
  2. Gather necessary equipment (pillows, positioning devices)
  3. Ensure adequate staff for safe movement
  4. Use a turn sheet or mechanical lift to reduce friction/shear
  5. Position patient at a 30-degree angle when side-lying (not 90 degrees)
  6. Use pillows to keep bony prominences from direct contact
  7. Float heels off the bed surface completely
  8. Document position change and skin condition

Key Points

  • Donut-shaped devices are contraindicated as they can cause pressure rings that increase tissue damage.
  • Prevention strategies should be individualized based on risk assessment findings and documented in the care plan.

Treatment and Management

Wound Assessment and Documentation

  • Comprehensive wound assessment includes measuring length, width, and depth; describing wound bed characteristics (granulation, slough, eschar); assessing wound edges and periwound skin; and documenting exudate amount and characteristics.
  • Documentation should be consistent and include staging, measurements, wound characteristics, pain levels, interventions performed, and patient response to treatment.

Clinical Scenario: Wound Assessment

A 78-year-old patient with limited mobility presents with a pressure injury on the sacrum. Upon assessment, you note a 4cm x 3cm x 0.5cm wound with 75% red granulation tissue and 25% yellow slough. The wound edges are attached, periwound skin is intact but slightly macerated. Moderate amount of serosanguineous drainage is present. Patient reports pain level of 3/10 during dressing changes.

Question: What stage would you classify this pressure injury?

Answer: This would be classified as a Stage 3 pressure injury based on the full-thickness tissue loss with visible subcutaneous fat (evidenced by depth and slough) without exposed bone, tendon, or muscle.

Key Points

  • Use consistent measuring techniques and documentation methods to accurately track wound healing progress.
  • Photograph wounds (with patient consent) to provide visual documentation of baseline and progress.

Wound Management Principles

  • Wound cleansing: Use normal saline or prescribed wound cleansers, avoiding cytotoxic agents like hydrogen peroxide or povidone-iodine on clean granulating wounds.
  • Debridement: Remove necrotic tissue through appropriate methods (autolytic, enzymatic, mechanical, or sharp) based on wound assessment and provider orders.
  • Infection control: Identify and manage signs of infection including increased pain, erythema, warmth, purulent drainage, or delayed healing.
  • Moisture balance: Select dressings that maintain appropriate moisture levels—keeping dry wounds moist and managing excess exudate in heavily draining wounds.
  • Nutritional support: Provide adequate protein (1.25-1.5 g/kg/day), calories, vitamins, and minerals to support tissue repair and wound healing.

Dressing Selection Guide

Dressing Type Indications Advantages Considerations
Transparent Film Stage 1, shallow Stage 2, protection Allows visualization, barrier to bacteria Not for exudating wounds, may damage fragile skin
Hydrocolloid Stage 2-3, minimal exudate Autolytic debridement, waterproof Not for infected wounds, may leave residue
Foam Stage 2-4, moderate to heavy exudate Highly absorbent, non-adherent Requires secondary dressing if non-adhesive
Alginate Stage 3-4, heavy exudate, tunneling Highly absorbent, hemostatic properties Requires moist wound bed, secondary dressing
Hydrogel Stage 2-4, dry wounds, necrotic tissue Hydrates wound bed, aids debridement Not for heavily exudating wounds
Negative Pressure Wound Therapy Stage 3-4, complex wounds Reduces edema, promotes granulation Contraindicated with malignancy, exposed vessels

Important Treatment Alert

Never place occlusive dressings over infected wounds as this can lead to abscess formation and systemic infection. Always assess for signs of infection before each dressing change and notify the provider if infection is suspected.

Key Points

  • Continue preventive measures during treatment phase to prevent additional pressure injuries.
  • Reassess wound healing progress at least weekly, with expectation of measurable improvement within 2-4 weeks of appropriate treatment.

Commonly Confused Points

Differential Diagnosis

  • Pressure injuries must be differentiated from other wound types such as moisture-associated skin damage (MASD), incontinence-associated dermatitis (IAD), medical adhesive-related skin injury (MARSI), and venous/arterial ulcers.
  • Key distinguishing factors include wound location, appearance, patient history, and precipitating factors.

Pressure Injury vs. Other Wound Types

Characteristic Pressure Injury Incontinence-Associated Dermatitis Venous Ulcer Arterial Ulcer
Location Bony prominences (sacrum, heels, ischium) Perineum, buttocks, inner thighs Medial lower leg, above ankle Toes, feet, lateral ankle
Appearance Circular/regular shape, varies by stage Diffuse erythema, denudation Irregular, shallow, ruddy base "Punched out" appearance, pale base
Edges Distinct wound margins Diffuse, poorly defined Irregular, sloping edges Well-defined, steep edges
Pain Variable, may be painless with neuropathy Burning, itching, tingling Aching, relieved with elevation Severe, worse with elevation
Cause Pressure, shear, friction Moisture, chemical irritation Venous hypertension Arterial insufficiency

Key Points

  • Accurate identification of wound etiology is essential for appropriate treatment selection.
  • Pressure injuries over bony prominences with a history of pressure or immobility are key diagnostic indicators.

Common Misconceptions and Errors

  • Staging vs. Healing: Pressure injuries do not "reverse stage" during healing. A healing Stage 4 pressure injury is not reclassified as Stage 3, 2, or 1 as it improves but remains a "healing Stage 4 pressure injury."
  • Friction vs. Shear: Friction is the force of two surfaces moving across each other, while shear is the force applied parallel to the skin surface causing tissues to slide in opposite directions, damaging deeper tissues.
  • Pressure relief vs. Pressure redistribution: Complete pressure relief (e.g., floating heels) removes all pressure from an area, while pressure redistribution (e.g., specialty mattresses) spreads pressure over a larger surface area.

Common Pitfalls Memory Aid: "SCALE"

Avoid these common errors in pressure injury management:

  • Staging errors (including reverse staging)
  • Cleansing with cytotoxic agents
  • Air-filled donut devices (contraindicated)
  • Lack of nutritional support
  • Excessive pressure on bony prominences

Key Points

  • Medicare considers Stage 3-4 pressure injuries acquired during hospitalization as "never events" that may not be reimbursed.
  • Documentation should use objective language (e.g., "pressure injury" rather than "bed sore" or "decubitus ulcer").

Study Tips and NCLEX Application

NCLEX Question Strategies

  • NCLEX questions on pressure injuries often focus on risk assessment, prevention strategies, staging identification, and appropriate interventions based on assessment findings.
  • Apply nursing process (assessment, diagnosis, planning, implementation, evaluation) when answering questions about pressure injury management.

Pressure Injury Priority Setting

When answering NCLEX questions about multiple patients, remember this priority order:

  1. Prevention for high-risk patients (highest priority)
  2. Early intervention for Stage 1 injuries
  3. Appropriate treatment based on staging
  4. Pain management during wound care
  5. Patient education for self-care/prevention

Key Points

  • For NCLEX questions about staging, focus on the deepest visible tissue layer to determine the correct stage.
  • Remember that prevention interventions take priority over treatment in most NCLEX questions.

Quick Review of Key Concepts

Quick Check: Pressure Injury Staging

Match the descriptions to the correct pressure injury stage:

  1. Intact skin with non-blanchable redness: Stage 1
  2. Partial-thickness loss with pink wound bed: Stage 2
  3. Full-thickness loss with visible subcutaneous fat: Stage 3
  4. Full-thickness loss with visible bone/tendon: Stage 4
  5. Purple/maroon intact skin or blood-filled blister: Deep Tissue Injury
  6. Full-thickness covered by slough/eschar: Unstageable

Essential NCLEX Concepts

  • Risk assessment using validated tools (Braden Scale)
  • Pressure injury staging system (Stages 1-4, Unstageable, DTI)
  • Prevention strategies (repositioning, support surfaces, skin care)
  • Wound assessment parameters (size, depth, tissue type, exudate)
  • Appropriate dressing selection based on wound characteristics
  • Differentiation between pressure injuries and other wound types

Self-Assessment Checklist

  • I can accurately identify the stages of pressure injuries
  • I understand the risk factors and prevention strategies
  • I can select appropriate interventions based on assessment
  • I can differentiate pressure injuries from other wound types
  • I understand the principles of wound care management
  • I can apply the nursing process to pressure injury care

Remember: Pressure injury prevention is a core nursing responsibility. Your vigilant assessment, timely interventions, and evidence-based care can prevent suffering and promote healing. Every skin assessment is an opportunity to make a difference in patient outcomes!

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